Dr Erin Morrison webinar slides (2)
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Best Practices in Psychiatry and Long Term Care:TELEPSYCHIATRY
Erin Morrison, MD
What is Telepsychiatry?Telepsychiatry, also known as e-psychiatry, is the application of telemedicine to the specialty field of psychiatry.
Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance.
Tele mental health care is the use of tele-communications technology to provide mental health services to individuals in communities or locations that are underserviced, typically as a result of geographic isolation. •Examples: providing health workers in remote areas with continuing education on mental health topics, videoconferenced consultations on routine and urgent mental health cases using a "virtual" case management team, and providing direct mental health care services through two-way interactive systems. One of the most controversial telemental health care applications is providing treatment services over the Internet directly.
Wikipedia, The Free Encyclopedia
1American Telemedicine Association
Provider and patient identity
and location
Patient appropriateness
Informed consent
Physical environment
Collaboration with treatment
teamMedical issues
Emergency management
Technical guidelines
Challenges and Benefits
Elements of Video-Based Mental Health
Services1
Provider + Patient Identity and Location
1American Telemedicine Association
Verify patient identity and location
(must verify patient location for provider state licensure
rules)
Contact information for provider and patient should
be exchange in case of dropped sessions or for
routine questions
Expectations regarding contact between sessions should be addressed prior
to the first session
Patient Appropriateness
“To date, no studies have identified any patient subgroup that does not benefit from, or is harmed by, mental healthcare provided
through remote videoconferencing.”1
• Home care setting-must consider degree of patient independence and have more comprehensive emergency plan in place
• Supervised setting- more issues with privacy
Situation dependent, but possible in both:
• Psychosis• Panic disorder• Cognitive impairment (though may not be appropriate for
unsupervised settings)
Diagnostic considerations-telepsychiatry has been successfully employed in patients with:
Informed Consent Are there any differences?
Informed consent process is the same as for face to face care, but must ALSO include (if applicable):
Confidentiality limits in electronic
communication
An agreed upon emergency plan
(patients in settings without clinical staff
immediately available)
Process by which patient information will be documented and
stored;
Conditions under which telepsychiatry services may be terminated and a referral made to face-
to-face care
It is very important to use language the patient can understand when discussing technical issues (such as data encryption or technical failure of equipment)
Physical Environment
Rooms/environments should be comparable to a standard services room
Ensure privacy so clinical discussion cannot be overheard
Presence of attendants or family members is situation dependent and subject to patient consent:
• to assist with orientation• to tend to audio or visual sensory deficits• for patient comfort (a familiar caretaker often eases patient anxiety)
For cognitively impaired patients it is often necessary for an attendant to be present in the room:
Communication and Collaboration with the Patient’s Treatment Team
Essential in the geriatric population
The geriatric patient often has multiple medical problems needing a full workup (appropriate laboratories, radiologic, and other diagnostic procedures). This communication can require more effort when one or more members of the treatment team is located at a remote site, but can still be accomplished.
Some solutions:• schedule monthly phone/video treatment team meetings• ensure all available records for other providers are
available during session• ensure that the facility (or other providers) have contact
information for the telepsychiatry provider
Medical work up
Ordering or prescriptions/ laboratory
studies
Follow up of laboratory or radiological
studies
Management of medication side effects
Referrals available for face to face
care
Coordinating Medical Issues-Who Does What?
Emergency Management
Based on the facility’s emergency procedures
Technical Guidelines
1American Telemedicine Association
Technical Contingencies
Backup plans include calling the patient or facility via telephone and attempting to troubleshoot the issue. Sessions may be continued by
telephone (situation dependent).
Technology “breakdown”• Poor/no audio• Poor/no video• Dropped sessions
Backup plans• Discussed with patient before session• Alternate contact information
Privacy
Recognized encryption standards for transmission of video & audio
• Federal Information Processing Standard• Advanced Encryption Standard (AES)
Physical environment (facility limitations)
Appropriate security of medical records
1American Telemedicine Association
Challenges
Remote facilities and available internet speed Patients with sensory impairments - The patient
end would ideally have large monitors, good audio capabilities, and high bandwidth and video resolution to make sure there is a large and clear picture for the elderly
Increased reliance on facility staff, e.g.: to assist with patients with disabilities,
to give limited physical exams (AIMS test), and
occasionally track down or confirm medication/lab values
Overall Benefits - Options!
Choice of providers Transportation Scheduling
Bottom Line: Delivering services to patients who would otherwise go without
References
1. Coleman, M., Dennison, O., Drude, K., Goldenson, M., Hirsch, P., Kramer, G., … Zucker, M. (2013). Practice Guidelines for Video-Based Online Mental Health Services-DRAFT. American Telemedicine Association. Retrieved from http://www.americantelemed.org/practice/standards/ata-standards-guidelines